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Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment and lending practices. The AAAAI Environmental Exposure and Respiratory Health (EERH) Committee and Diversity, Equity and Inclusion (DEI) Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and healthcare. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

To determine if the addition of home environmental control strategies (ECSs) to controller medication titration reduces asthma controller medication requirements and in-home allergen concentrations among children with persistent asthma in Baltimore City. 155 children ages 5–17 with allergen-sensitized asthma were enrolled in a 6-month randomized clinical trial of multifaceted, individually-tailored ECS plus asthma controller medication titration compared to controller medication titration alone. Participants had to meet criteria for persistent asthma and have had an exacerbation in the previous 18 months. Allergen sensitization (mouse, cockroach, cat, dog, dust mite) was assessed at baseline and home dust allergen concentrations were measured at baseline, 3 and 6 months. ECS was delivered 3–4 times over the trial. Asthma controller medication was titrated using a guidelines-based algorithm at baseline, 2, 4, and 6 months. The primary outcome was controller medication treatment step at 6 months (0–6, as-needed albuterol to high-dose ICS + LABA). The population was predominately Black (90%), on public insurance (93%), and male (61%). The mean age was 10.1 years (SD 3.3). More than 70% were sensitized to a rodent, >50% to cockroach, and 70% were polysensitized. At 6 months, there were no differences in either treatment step (3.8 [SD 1.4] vs. 3.7 [SD 1.5]) or allergen concentrations between groups. Among this predominantly low-income, Black pediatric asthma population, the addition of ECS to controller medication titration reduced neither indoor allergen concentrations nor controller medication requirements compared to controller medication titration alone.

BACKGROUND/OBJECTIVES: We sought to quantify the reliability and validity of remote atopic dermatitis (AD) severity assessment using the Eczema Area and Severity Index (EASI) applied to caregiver-provided photos (p-EASI) and videos (v-EASI). METHODS: Children (0–17 years) with a physician diagnosis of AD were recruited. Caregivers took photos and a video of their child’s skin. A clinician scored in-person EASI on the same day, then p-EASI and v-EASI for each participant ten days or more between ratings. Two additional clinicians scored p-EASI and v-EASI. Lin’s concordance correlation coefficient (CCC) was employed to assess criterion validity using in-person EASI as the gold standard. Intraclass correlation coefficients (ICC) were calculated to assess interrater reliability of p-EASI and v-EASI. RESULTS: Fifty racially and ethnically diverse children (age (mean±SD): 4.3±4.4 years; 42% female) with a range of AD severity (EASI: 6.3±6.4) and Fitzpatrick Skin Types (1–2: 9%; 3–4: 60%; 5–6: 31%) were enrolled and received in-person EASI assessment. Fifty had p-EASI and 49 had v-EASI by the same in-person rater, and by two additional raters. The CCC and ICC for p-EASI were 0.89, 95% CI [0.83, 0.95]; and 0.81, 95% CI [0.71, 0.89], respectively. The CCC and ICC for v-EASI were 0.75, 95% CI [0.63, 0.88]; and 0.69, 95% CI [0.51, 0.81], respectively. CONCLUSIONS: In this diverse population with a range of skin tones, p-EASI showed good criterion validity and good interrater reliability. v-EASI showed moderate to good criterion validity and moderate interrater reliability. Both may be reliable and valid options for remote AD severity assessment.

Rationale Environmental exposures have been associated with adverse outcomes in COPD. Approximately one third of individuals with COPD have allergic sensitization, but it is unknown whether exposure to allergens in the home are associated with outcomes. Objectives To determine the prevalence and associations of allergen sensitization with exposure to common indoor allergens with symptoms and exacerbation risk in COPD. Methods Allergen sensitization to five common indoor allergens was assessed in former smokers with COPD. Home settled dust was assessed for presence of corresponding allergens. Sensitization and exposure status were determined and associations evaluated in adjusted models with longitudinal outcomes including symptoms, lung function and exacerbations. Interactions were assessed between sensitization/exposure status and lung function. Measurements and Main Results One hundred eighty-three individuals studied were on average 67.3 years old (SD 8.22) with average FEV1 of 53.2 % (SD 17.6%). Seventy-seven percent of participants were exposed to at least one tested allergen, and 17% had sensitization with corresponding allergen exposure. After adjustment, sensitization with exposure was associated with lower lung function (β -8.29, 95% CI -14.80 to -1.77), higher SGRQ (β 6.71, 95% CI 0.17 to 13.25) and higher exacerbation risk (OR 2.31, 95% CI 1.11 to 4.79). Associations appeared to be more pronounced among individuals with lower lung function. Conclusions Allergen exposures are common in COPD and associated with adverse outcomes among those with concomitant allergen sensitization. This study establishes allergens as an important home exposure that potentially could be addressed with comprehensive home environmental modification strategies to improve COPD outcomes.

Purpose of Review As telemedicine gains popularity among providers and patients alike, it is important to ensure the standards of care remain equivalent between the in-person and virtual settings. While bedside manner remains a key competency incorporated into medical school curricula, “webside manner,” or professional standards for virtual care, remains less defined. Recent Findings Best practices exist including guidance prior to the visit, methods to maintain a professional background environment, and translation of core communication competencies for a video interaction. Through application of these practices, a provider can ensure the core interpersonal and communication competencies are fulfilled. These practices have direct application to allergy, asthma, and immunology care. Summary This review provides an overview of best practices for professionalism and patient interaction for virtual care and examines specific applications to allergy, asthma, and immunology visits

Objective To synthesize the growing body of literature on the role of social determinants of health (SDoH) in asthma and asthma disparities. Data Sources A pubmed.gov search was performed to identify published literature on SDoH, asthma, asthma disparities, and race and ethnicity. Current asthma statistics of the Centers for Disease Control and Prevention were reviewed. Study Selections Relevant articles on SDoH, asthma, asthma disparities, and race and ethnicity were reviewed in detail. Results Black and Latinx Americans have a higher asthma prevalence and greater asthma morbidity than White Americans and also bear a disproportionate burden of SDoH. Inequities in SDoH are rooted in structural racism and population-level injustices that affect the socioeconomic status, physical environment, and health care access/quality of Black and Latinx Americans. There is evidence that racial/ethnic inequities in SDoH, such as socioeconomic status, neighborhood environment, housing, environmental exposures, and health care access/quality, contribute to excess burden of asthma prevalence/incidence, morbidity, exacerbations, and abnormal lung function among certain racial/ethnic populations. In addition, Black and Latinx communities experience high levels of long-term stress, which may increase asthma risk through direct effects on the immune system and hypothalamic-pituitary-adrenocortical activation. Long-term stress may also mediate the effects of SDoH on asthma. Conclusion Although there is clear evidence linking SDoH to excess asthma risk and implicating SDoH in asthma disparities, the extent to which asthma disparities are explained by inequities in SDoH and the relative contributions of each of these SDoH to asthma disparities remain unclear. This knowledge is needed to effectively develop and test systems-level interventions targeting SDoH, with the ultimate goal of meaningfully reducing racial/ethnic asthma disparities.

People of color and lower socioeconomic status groups in the USA, including those of Mexican origin, are exposed to higher concentrations of air pollution, including fine particulate matter (PMA sample of 604 linguistically isolated Mexican-origin families in central TX provided data on demographic and psychosocial experiences. Outdoor air pollution concentrations at participants' home addresses were based on high-resolution estimates of fine particulate matter (PMLower PMThere are limits to assimilation for Mexican immigrant families. Living in more advantaged neighborhoods is associated with experiencing better air quality, but this advantage may come at the cost of experiencing more ethnic discrimination.

Asthma is a common, complex heterogeneous disease often beginning in early life and is characterized by reversible airflow obstruction. The phenotypic differences that exist in children with asthma may impact underlying comorbid conditions and pharmacologic treatment choices. Prenatal factors for increased risk of asthma could include maternal diet and the maternal microbiome. Evidence also suggests that postnatal microbial exposures and colonization contribute to the risk of allergic diseases and asthma. After confirming the diagnosis, asthma management in children centers on 3 broad areas: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers on the importance of adherence and device technique. Moreover, social determinants of health significantly impact on symptom burden and treatment response.

ImportanceStructural racism has been implicated in the disproportionally high asthma morbidity experienced by children living in disadvantaged, urban neighborhoods. Current approaches designed to reduce asthma triggers have modest impact.ObjectiveTo examine whether participation in a housing mobility program that provided housing vouchers and assistance moving to low-poverty neighborhoods was associated with reduced asthma morbidity among children and to explore potential mediating factors.Design, Setting, and ParticipantsCohort study of 123 children aged 5 to 17 years with persistent asthma whose families participated in the Baltimore Regional Housing Partnership housing mobility program from 2016 to 2020. Children were matched to 115 children enrolled in the Urban Environment and Childhood Asthma (URECA) birth cohort using propensity scores.ExposureMoving to a low-poverty neighborhood.Main OutcomesCaregiver-reported asthma exacerbations and symptoms.ResultsAmong 123 children enrolled in the program, median age was 8.4 years, 58 (47.2%) were female, and 120 (97.6%) were Black. Prior to moving, 89 of 110 children (81%) lived in a high-poverty census tract (>20% of families below the poverty line); after moving, only 1 of 106 children with after-move data (0.9%) lived in a high-poverty tract. Among this cohort, 15.1% (SD, 35.8) had at least 1 exacerbation per 3-month period prior to moving vs 8.5% (SD, 28.0) after moving, an adjusted difference of −6.8 percentage points (95% CI, −11.9% to −1.7%; P = .009). Maximum symptom days in the past 2 weeks were 5.1 (SD, 5.0) before moving and 2.7 (SD, 3.8) after moving, an adjusted difference of −2.37 days (95% CI, −3.14 to −1.59; P Conclusions and RelevanceChildren with asthma whose families participated in a program that helped them move into low-poverty neighborhoods experienced significant improvements in asthma symptom days and exacerbations. This study adds to the limited evidence suggesting that programs to counter housing discrimination can reduce childhood asthma morbidity.

There are marked disparities in asthma-related emergency department (ED) visit rates among children by race and ethnicity. Following the implementation of coronavirus disease 2019 (COVID-19) prevention measures, asthma-related ED visits rates declined substantially. The decline has been attributed to the reduced circulation of upper respiratory viruses, a common trigger of asthma exacerbations in children.To better understand the contribution of respiratory viruses to racial and ethnic disparities in ED visit rates, we investigated whether the reduction in ED visit rates affected Black, Latinx, and White children with asthma equally.Asthma-related ED visits were extracted from electronic medical records at Dell Children's Medical Center in Travis County, Texas. ED visit rates among children with asthma were derived by race/ethnicity. Incidence rate ratios (IRRs) and 95% CIs were estimated by year (2019-2021) and season.In spring 2019, the ED visit IRRs comparing Black children with White children and Latinx children with White children were 6.67 (95% CI = 4.92-9.05) and 2.10 (95% CI = 1.57-2.80), respectively. In spring 2020, when infection prevention measures were implemented, the corresponding IRRs decreased to 1.73 (95% CI = 0.90-3.32) and 0.68 (95% CI = 0.38-1.23), respectively.The striking reduction of disparities in ED visits suggests that during nonpandemic periods, respiratory viruses contribute to the excess burden of asthma-related ED visits among Black and Latinx children with asthma. Although further investigation is needed to test this hypothesis, our findings raise the question of whether Black and Latinx children with asthma are more vulnerable to upper respiratory viral infections.

Air trapping is an obstructive phenotype that has been associated with more severe and unstable asthma in children. Air trapping has been defined using pre- and postbronchodilator spirometry. The causes of air trapping are not completely understood. It is possible that environmental exposures could be implicated in air trapping in children with asthma.We investigated the association between indoor exposures and air trapping in urban children with asthma.Children with asthma aged 5 to 17 years living in Baltimore and enrolled onto the Environmental Control as Add-on Therapy for Childhood Asthma study were evaluated for air trapping using spirometry. Aeroallergen sensitization was assessed at baseline, and spirometry was performed at 0, 3, and 6 months. Air trapping was defined as an FVC z score of less than -1.64 or a change in FVC with bronchodilation of ≥10% predicted. Logistic normal random effects models were used to evaluate associations of air trapping and indoor exposures.Airborne and bedroom floor mouse allergen concentrations were associated with air trapping but not airflow limitation (odds ratio 1.19, 95% confidence interval 1.02-1.37, P = .02 per 2-fold increase in airborne mouse allergen; odds ratio 1.23, 95% confidence interval 1.07-1.41, P = .003 per 2-fold increase in bedroom floor mouse allergen). Other indoor exposures (cockroach, cat, dog, dust mite, particulate matter, and nicotine) were not associated with air trapping or airflow limitation.Mouse allergen exposure, but not other indoor exposure, was associated with air trapping in urban children with asthma.

Background Little is known about the concordance of atopy with asthma COPD overlap. Among individuals with COPD, a better understanding of the phenotypes characterized by asthma overlap and atopy is needed to better target therapies. Research Question What is the overlap between atopy and asthma status among individuals with COPD, and how are categories defined by the presence of atopy and asthma status associated with clinical and radiologic phenotypes and outcomes in the Genetic Epidemiology of COPD Study (COPDGene) and Subpopulation and Intermediate Outcome Measures in COPD Study (SPIROMICS)? Study Design and Methods Four hundred three individuals with COPD from SPIROMICS and 696 individuals from COPDGene with data about specific IgEs to 10 common allergens and mixes (simultaneous assessment of combination of allergens in similar category) were included. Comparison groups were defined by atopic and asthma status (neither, atopy alone, atopic asthma, nonatopic asthma, with atopy defined as any positive specific IgE (≥0.35 KU/L) to any of the 10 allergens or mixes and asthma defined as self-report of doctor-diagnosed current asthma). Multivariable regression analyses (linear, logistic, and zero inflated negative binomial where appropriate) adjusted for age, sex, race, lung function, smoking status, pack-years smoked, and use of inhaled corticosteroids were used to determine characteristics of groups and relationship with outcomes (exacerbations, clinical outcomes, CT metrics) separately in COPDGene and SPIROMICS, and then adjusted results were combined using meta-analysis. Results The prevalence of atopy was 35% and 36% in COPD subjects from SPIROMICS and COPDGene, respectively, and less than 50% overlap was seen between atopic status with asthma in both cohorts. In meta-analysis, individuals with nonatopic asthma had the most impaired symptom scores (effect size for St. George's Respiratory Questionnaire total score, 4.2; 95% CI, 0.4-7.9; effect size for COPD Assessment Test score, 2.8; 95% CI, 0.089-5.4), highest risk for exacerbations (incidence rate ratio, 1.41; 95% CI, 1.05-1.88) compared with the group without atopy or asthma. Those with atopy and atopic asthma were not at increased risk for adverse outcomes. Interpretation Asthma and atopy had incomplete overlap among former and current smokers with COPD in COPDGene and SPIROMICS. Nonatopic asthma was associated with adverse outcomes and exacerbation risk in COPD, whereas groups having atopy alone and atopic asthma had less risk.

Heat exposure of a population is often estimated by applying temperatures from outdoor monitoring stations. However, this can lead to exposure misclassification if residents do not live close to the monitoring station and temperature varies over small spatial scales due to land use/built environment variability, or if residents generally spend more time indoors than outdoors. Here, we compare summertime temperatures measured inside 145 homes in low-income households in Baltimore city with temperatures from the National Weather Service weather station in Baltimore. There is a large variation in indoor temperatures, with daily-mean indoor temperatures varying from 10 °C lower to 10 °C higher than outdoor temperatures. Furthermore, there is only a weak association between the indoor and outdoor temperatures across all houses, indicating that the outdoor temperature is not a good predictor of the indoor temperature for the residences sampled. It is shown that much of the variation is due to differences in the availability of air conditioning (AC). Houses with central AC are generally cooler than outdoors (median difference of − 3.4 °C) while those with no AC are generally warmer (median difference of 1.4 °C). For the collection of houses with central or room AC, there is essentially no relationship between indoor and outdoor temperatures, but for the subset of houses with no AC, there is a weak relationship (correlation coefficient of 0.36). The results presented here suggest future epidemiological studies of indoor exposure to heat would benefit from information on the availability of AC within the population.

INTRODUCTION: Atopic dermatitis (AD) is a common chronic childhood illness. It is often treated by primary care providers (PCPs) though may require referral to a dermatology specialist. METHODS: We administered an exploratory survey to 50 caregivers of children ages 0 – 17 years with AD to assess their preferences and barriers toward accessing dermatology specialty care for their child’s AD. RESULTS: Caregivers felt PCPs and specialists equally listened to concerns about their child’s AD. However, many felt there was a difference in the care provided and control of the AD and preferred to see a specialist for ongoing management. DISCUSSION: Caregivers may benefit from their children being referred to dermatology specialists earlier and more often for their AD. Further work must be done to characterize preferences and barriers toward AD care across race and ethnicity.

Background Insulin-like growth factors (IGFs), and their binding proteins (IGFBPs), play a significant role in cardiovascular function and may influence the pathobiology of PAH. We determined the diagnostic and prognostic value of IGF1 and IGFBP2 in pediatric PAH. Methods Serum was analyzed by ELISA for IGF1 and IGFBP2 in pediatric PAH subjects from the NHLBI PAH Biobank (PAHB, n = 175) and a cohort of asthmatic subjects (n = 46, age 0-21 years) as a chronic pediatric pulmonary disease control. Biomarkers were analyzed with demographic and clinical variables for PAH severity. Results Serum IGF1 was significantly lower in PAH compared to controls, while IGFBP2 was elevated in PAH subjects compared to controls. In the PAHB, IGF1 was negatively associated with mPAP and PVR, while IGFBP2 was positively associated with PVR and negatively associated with cardiac output and 6-min walk distance. Higher IGFBP2 levels were associated with use of prostacyclin therapy. IGFBP2 was associated with death, transplant, or palliative shunt with a Cox proportional hazard ratio of 8.8 (p Conclusions Circulating IGFBP2 is a novel marker for pediatric PAH, which is associated with worse functional status, and survival. IGF axis dysregulation may be an important mechanistic target in pediatric pulmonary arterial hypertension. Impact Pediatric pulmonary hypertension is a severe disease, with poorly understood pathobiology.There are few studies looking at the pathobiology of pulmonary hypertension only in children.The IGF axis is dysregulated in pediatric pulmonary arterial hypertension.IGF axis dysregulation, with increased IGFBP2, is associated with worse clinical outcomes in pediatric pulmonary artery hypertension.IGF axis dysregulation gives new insight into the disease process and may be a mechanistic or therapeutic target.Fig. 1IGF1 AND IGFBP2 CONCENTRATION (NG/ML) IN PAH BIOBANK VERSUS CONTROLS.: a IGF1 concentration (ng/mL) in PAH Biobank versus asthmatic subjects. b IGFBP2 concentration (ng/mL) in PAH Biobank versus asthmatic subjects.Fig. 2ROC CURVE OF IGF1 AND IGFBP2 IN PAH BIOBANK VERSUS CONTROLS.: a ROC curve of IGF1 in PAH Biobank subjects versus controls. AUC 0.82. Cut point for IGF1 of 177 ng/mL gives a sensitivity of 73.9% and a specificity of 78.3%. b ROC curve of IGFBP2 in PAH Biobank subjects versus controls. AUC 0.80. Cut point for IGFBP2 of 185 ng/mL gives a sensitivity of 72.2% and a specificity of 80.4%.Fig. 3IGFBP2 CONCENTRATIONS IN PAH SUBJECTS BY MEDICATION COMBINATION.: a IGFBP2 concentration in PAH subjects on a PDE5 inhibitor, a PDE5 inhibitor and an ERA, a PDE5 inhibitor and IV/SQ PCA, or a combination of PDE5 inhibitor, ERA, and IV/SQ PCA. b IGFBP2 concentrations in PAH subjects on an IV/SQ PCA and any other therapy versus subject not on IV/SQ PCA and any other therapy.Fig. 4Kaplan-Meier curve showing time to death, transplant, or palliative shunt (Pott's shunt or atrial septostomy) dichotomized by the median IGFBP2 level.

Background Allergen extracts are the primary tool for diagnosis and treatment of allergic diseases. In the United States, most allergen extracts are non-standardized. More sophisticated analytical approaches are needed to characterize these products and enable manufacturers and regulators to better determine potency. Objective To expand the multiple reaction monitoring (MRM) assay for an in-depth characterization of German cockroach (GCr; Blattella germanica) allergen extracts. Methods We applied advanced liquid chromatography (LC) and mass spectrometry (MS) techniques including MRM. The expanded LC/MRM-MS method was optimized to measure known GCr allergens and their isoforms/variants in commercial extracts and environmental samples. We performed isoform-specific allergen measurements in multiple extracts from four commercial sources and extracts prepared using environmental samples from urban homes. To investigate causes of heterogeneity, we examined over 30 extraction process variables. Results Evaluation of the commercial extracts confirmed the variability of production lots and commercial sources. Commonly used defatting and extraction protocols yielded extracts with comparable allergen profiles and content. However, the identity and quality of source materials was a major contributor to variability. In comparing commercial GCr extracts to environmental samples, relative quantities of Bla g 1, Bla g 2, Bla g 3, Bla g 4 and Bla g 11 were similar, while Bla g 5, Bla g 6, Bla g 7 and Bla g 8 were present in the environmental samples but largely absent for the commercial extracts. Conclusions and clinical relevance LC/MRM-MS can be used to measure all known GCr allergens in commercial allergen extracts and environmental samples. Significant differences exist between allergen profiles of commercial extracts and the profiles of environmental samples from dwellings. This analytical platform can serve as a template to achieve better product characterization of similarly complex products.

Phthalates are synthetic chemicals present in building materials, personal care products and other consumer goods. Limited studies link phthalates to pediatric asthma incidence; however, their effects on respiratory-related outcomes among those with pre-existing asthma remains unclear.We examined associations between phthalates and asthma symptoms, healthcare use, lung function, and lung inflammation among children with asthma.We collected repeated measures of urinary biomarkers for select phthalates and phthalate replacements (MBzP, MCINP, MCIOP, MCPP, MECPTP, MEHHTP, molar sum of DEHP biomarkers [MECPP, MEHHP, MEHP, MEOHP], MEP, MiBP, MnBP) and asthma symptoms, healthcare utilization, lung function, and inflammation among 148 predominantly low-income Black children (5-17 years) with persistent asthma every 3 months for one year. We used generalized estimating equations to assess associations between biomarker concentrations and asthma-related measures adjusting for age, sex, race/ethnicity, caregiver's education level, presence of smokers in the home, and season. We also considered co-exposures to other contaminants previously associated with asthma morbidity.We observed consistent positive associations with individual DEHP biomarkers, the molar sum of DEHP, and BBzP with increased odds of asthma symptoms and with healthcare utilization (adjusted Odds Ratio for general asthma symptoms: ΣDEHP:1.49,95% Confidence Interval, CI:1.08-2.07; BBzP:1.34, CI:1.04-1.73). We observed similar associations between the DEHP phthalate replacement biomarker MEHHTP and most asthma symptoms evaluated; and with select low molecular weight phthalates (DiBP, DBP) and healthcare utilization. Results were similar when controlling for other environmental exposures (e.g., PMIn the present study, we found evidence to suggest that exposure to select phthalates may be associated with asthma symptoms and healthcare utilization. These findings warrant confirmation given the high asthma burden and widespread and disparate phthalate exposures reported among select populations of color.

As we look towards post-pandemic health delivery, the role of telehealth must be examined. We use the RE-AIM framework to discuss the challenges and successes of telehealth during the pandemic in the United States, and propose critical aspects to consider for optimizing telehealth care in the future.

A growing body of epidemiological data indicates that the prevalence and public health burden of asthma and other common allergic conditions (eg, atopic dermatitis, food allergy, allergic rhinitis, and drug allergy) is greatest among certain historically marginalized populations. However, these historically marginalized populations are often under-represented in research aiming to better understand, treat, and prevent these chronic conditions, raising concerns about the generalizability of the resulting study findings to those who are most affected. In a country as heterogeneous as the United States, with respect to race and ethnicity, socioeconomic status, culture, geography, and behavior, researchers aiming to characterize the burden of allergic disease, evaluate treatments, and/or better understand its mechanisms must pay particular attention to whether their samples are sufficiently diverse and representative in order to maximize the validity-and scientific utility-of the resulting data. Therefore, the goal of this clinical commentary is to highlight the need for improved, more thoughtful representation of the full diversity of affected populations in allergy/immunology research and share best practices for study design, recruitment, retention, and data analysis, so that both the research process and products can have maximal public health impact.

Background Neighborhood and caregiver characteristics have each been linked to children's asthma outcomes, but less is known about how caregiver psychosocial functioning may explain the link between neighborhood characteristics and asthma outcomes. Objective To examine associations between neighborhood safety, caregiver stress and depressive symptoms, and children's asthma outcomes, and to evaluate whether caregiver stress and depressive symptoms mediate the relationship between neighborhood safety and asthma outcomes. Methods We analyzed baseline data from a prospective cohort study of the effects of a housing mobility program on children's asthma-related outcomes. Age- and sex-adjusted models evaluated associations of neighborhood safety, and caregiver stress and depressive symptoms, with children's asthma symptoms and exacerbations. Results Participants were 140 low-income children with persistent asthma (98% Black participants; 53% males; mean age, 9.0 years) with an average of 7.1 ± 5.3 maximum symptom days per 2 weeks. Lower neighborhood safety, and higher caregiver stress and depressive symptoms, were associated with higher asthma symptoms, but not exacerbations, in adjusted models (eg, for neighborhood safety, maximum symptom days: odds ratio, 1.41; 95% CI, 1.07-1.88; for caregiver stress, maximum symptom days: odds ratio, 1.08; 95% CI, 1.01-1.15; for depressive symptoms, maximum symptom days: odds ratio, 1.05; 95% CI, 1.00-1.11). Exploratory analyses suggested that caregiver stress partially mediated associations between neighborhood safety and asthma symptoms for children in unsafe neighborhoods. Conclusions Neighborhood safety was associated with children's asthma symptoms independent from caregiver stress and depressive symptoms, although for children in unsafe neighborhoods, caregiver stress may partially mediate this association. Findings suggest the importance of targeting multiple systems to improve children's asthma outcomes.

There is an evolving body of literature that links chemicals commonly found in personal care products (PCPs) to an increased risk of both developing asthma and worsening existing asthma. Phthalates, parabens, environmental phenols, such as triclosan and bisphenol A (BPA), and other endocrine disrupting compounds (EDCs) have been implicated in asthma and related allergic conditions in epidemiological studies. Because Black individuals have increased exposure to these chemicals through hair care products and feminine hygiene products, disproportionate exposure to these chemicals through PCPs could contribute, in part, to the disproportionate asthma prevalence and morbidity among the US Black population. Increased exposure to these chemicals among Black individuals is explained, in part, by more frequent use of hair care products that can contain higher concentrations of these chemicals and greater use of feminine hygiene products, which are also sources of exposure to these chemicals. Epidemiologic evidence using urinary biomarkers of exposure demonstrates associations between PCPs and exposure to these chemicals and that the US Black population has greater exposure to these chemicals compared with the non-Black population. Should chemical exposures through PCPs contribute to the excess burden of asthma among the US Black population, reducing these exposures would reduce this disparity.

SummaryDuring most of 2020, the COVID-19 pandemic gave rise to considerable and growing numbers of hospitalizations across most of the U.S. Typical COVID-19 hospitalization data, including length of stay, intensive care unit (ICU) use, mechanical ventilation (Vent), and in-hospital mortality provide clearly interpretable health care endpoints that can be compared across population strata. They capture the resources consumed for the care of COVID-19 patients, and analysis of these endpoints can be used for resource planning at the local level. Yet, hospitalization data embody novel features that require careful statistical treatment to be useful in this context. Specifically, statistical models must meet three goals: (i) They should mesh with and inform mathematical epidemiologic or agent-based models of the COVID-19 experience in the population. (ii) They need to handle administrative censoring of hospitalization experience when data are extracted and downloaded for a given patient before that patient’s hospitalization experience has terminated. And, (iii) models need to handle risks for competing events, the occurrence of one blocking the possibility of the other(s). For example, live discharge from the hospital “competes with” (i.e., blocks) in-hospital mortality. We have adapted approaches from the survival analysis literature to address these challenges in order to better understand and quantify the population experience in hospital with respect to length of stay, ICU, Vent use and so on. Using hospitalization data from a large U.S. metropolitan region, in this report, we show how standard techniques from survival analysis can be brought to bear to address these challenges and yield interpretable results. In the breakout/discussion, we will discuss formulation, estimation and inference, and interpretation of competing risks models.

BACKGROUND: Urban minority children are at risk for poor asthma outcomes and may not receive appropriate primary or subspecialty care. OBJECTIVE: We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma. METHODS: The Barriers to Care Questionnaire (BCQ) measures expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control via TRACK and these outcomes: PCP visits for asthma in past six months, subspecialty care (allergist or pulmonologist) in past two years, and ED visits in past three months. RESULTS: 395 caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent(N=236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (OR 0.95, p=0.014) and subspecialty visits (OR 0.92, p=0.019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR 0.98, p=0.027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes. CONCLUSIONS: Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the healthcare system (marginalization). Clinicians who serve at-risk populations should be sensitive to families’ past experiences and should consider designing interventions to target the most commonly reported barriers. WHAT’S NEW: In a group of preschool-age, urban, predominantly African-American children with asthma, caregiver-reported barriers related to marginalization were associated with decreased likelihood of primary and subspecialty asthma care, indicating a potential target for future interventions to improve asthma outcomes.

BACKGROUND: African-American and Latinx children suffer from higher rates of uncontrolled asthma and poorer outcomes compared to white children. Sociocultural factors play a prominent role in how caregivers navigate asthma control for their children. OBJECTIVES: 1) Explore the knowledge, perceptions and behaviors of Latinx and African-American caregivers related to their children’s asthma and identify barriers to achieving asthma control; and 2) Elicit caregiver responses to messaging materials intended to help them better recognize uncontrolled asthma and seek timely medical treatment. METHODS: Study participants were recruited and screened to meet the following inclusion criteria: African-American or Latinx race/ethnicity, household income at or below 185% of the federal poverty line, and at least one child diagnosed with asthma with symptom frequency consistent with uncontrolled asthma according to national guidelines. Participants attended one of three moderator-led focus groups. The transcripts were qualitatively analyzed using a thematic analysis approach. RESULTS: Themes emerged among the nineteen participants related to asthma assessment, management, emotion, support, and trust. Caregivers exhibited gaps in their asthma knowledge, especially pertaining to the term “asthma control”. Caregivers generally worried about asthma emergencies more than the daily impairments caused by uncontrolled asthma. Many were uncomfortable using daily controller medications, citing issues of provider trust and side effect concerns. Caregivers did not recognize uncontrolled asthma in their own child, even after viewing messaging materials informing them of symptom frequency criteria. CONCLUSION: Culturally tailored interventions, including public asthma messaging, should address low trust in provider recommendations and caregiver concerns about controller medications.

BACKGROUND Mouse allergy is an important cause of indoor asthma and allergic rhinoconjunctivitis. The major mouse allergen, Mus m 1, is a complex of homologous pheromone-binding lipocalins called major urinary proteins (MUPs). METHODS We analyzed the proteome of MUPs in mouse urine, commercial mouse epithelial extracts, and environmental samples using several approaches. These include as follows: two-dimensional electrophoresis and immunoblotting; liquid chromatography-high-resolution mass spectrometry (LC/HRMS); multiple reaction monitoring (MRM) mass spectrometry; and LC/HRMS analysis of glycans at the N-66 residue of MUP3. RESULTS Albumin is predominant in the extracts, while MUPs are predominant in urine. LC/HRMS of 4 mouse allergen extracts revealed surprising heterogeneity. Of 22 known mouse MUPs, only 6 (MUP3, MUP4, MUP5, MUP13, MUP20, and MUP21) could be identified with MRM using unique peptides. Assessment of MUP content in urine, extracts, and dust samples showed good correlation between MRM and other methods working with different detection principles. All 6 identifiable MUPs were found in electrophoretically separated urine bands, but only MUP3 and MUP20 were above LOQ in unseparated mouse urine, and only MUP3, MUP4, and MUP20 were found in mouse epithelial extracts. Glycan heterogeneity was noted among 4 individual inbred mice: of 13 glycan structures detected, 8 were unique to one mouse, and only 2 glycan modifications were present in all 4 mice. CONCLUSIONS Using mass spectrometry and MRM, mouse allergen extracts and urine samples are shown to be complex and heterogeneous. The efficacy and safety of commercial mouse allergen extracts will be improved with better controls of allergen content.

Background: Significant disparities exist in pediatric asthma outcomes, with African American and Hispanic children suffering from higher rates of uncontrolled asthma compared to white children. Racial/ethnic identity and cultural and socioeconomic factors often play a significant role in how caregivers navigate asthma control for their children. Objectives: The purpose of this study was to 1) Elicit the knowledge, perceptions and behaviors of Latinx and African American caregivers related to their children’s asthma; 2) Identify knowledge gaps, cultural norms, and other barriers to asthma management, and …

BackgroundLittle is known about the concordance of atopy with asthma COPD overlap. Among individuals with COPD, a better understanding of the phenotypes characterized by asthma overlap and atopy is needed to better target therapies.Research questionWhat is the overlap between atopy and asthma status among individuals with COPD, and how are categories defined by the presence of atopy and asthma status associated with clinical and radiologic phenotypes and outcomes in the Genetic Epidemiology of COPD Study (COPDGene) and Subpopulation and Intermediate Outcome Measures in COPD Study (SPIROMICS)?Study design and methodsFour hundred three individuals with COPD from SPIROMICS and 696 individuals from COPDGene with data about specific IgEs to 10 common allergens and mixes (simultaneous assessment of combination of allergens in similar category) were included. Comparison groups were defined by atopic and asthma status (neither, atopy alone, atopic asthma, nonatopic asthma, with atopy defined as any positive specific IgE (≥0.35 KU/L) to any of the 10 allergens or mixes and asthma defined as self-report of doctor-diagnosed current asthma). Multivariable regression analyses (linear, logistic, and zero inflated negative binomial where appropriate) adjusted for age, sex, race, lung function, smoking status, pack-years smoked, and use of inhaled corticosteroids were used to determine characteristics of groups and relationship with outcomes (exacerbations, clinical outcomes, CT metrics) separately in COPDGene and SPIROMICS, and then adjusted results were combined using meta-analysis.ResultsThe prevalence of atopy was 35%and 36%in COPD subjects from SPIROMICS and COPDGene, respectively, and less than 50%overlap was seen between atopic status with asthma in both cohorts. In meta-analysis, individuals with nonatopic asthma had the most impaired symptom scores (effect size for St. George's Respiratory Questionnaire total score, 4.2; 95%CI, 0.4-7.9; effect size for COPD Assessment Test score, 2.8; 95%CI, 0.089-5.4), highest risk for exacerbations (incidence rate ratio, 1.41; 95%CI, 1.05-1.88) compared with the group without atopy or asthma. Those with atopy and atopic asthma were not at increased risk for adverse outcomes.InterpretationAsthma and atopy had incomplete overlap among former and current smokers with COPD in COPDGene and SPIROMICS. Nonatopic asthma was associated with adverse outcomes and exacerbation risk in COPD, whereas groups having atopy alone and atopic asthma had less risk.

* Abbreviations: AD — : atopic dermatitis FENO — : fractional exhaled nitric oxide Striking racial and ethnic disparities in childhood health conditions, such as prematurity, obesity, and asthma, have persisted despite decades of research focused on reducing these disparities. Although major advances in the treatment of chronic health conditions are difficult to achieve, an understanding of the underlying biology of disease has led to breakthroughs in the treatment of common childhood diseases such as asthma. It is notable, however, that despite the successes of biology-focused research, racial and ethnic disparities persist across many pediatric health conditions, suggesting that an exclusive focus on biology is a failed strategy for reducing these disparities. To make meaningful progress in improving minority health and disparities, the biomedical framework of health sciences must be recast so that it explicitly incorporates social context,1 which includes factors such as socioeconomic status, environmental exposures, access to high quality health care, and racism. Because the pediatric field has long understood that contextual factors have profound effects on health, it is best positioned to lead this recasting of health disparities research. Much health disparities research has been misguided in its framing of race and ethnicity as biological concepts, when socioeconomic and other contextual factors dwarf potential effects of innate biology.2–4 We have relied on a framework of biomedical research that tends to be uninterested in context and, instead, obsessed with using the latest technology to measure more easily quantifiable biological characteristics, which may not underpin differences in the expression of disease among populations. In addition, observed associations between biological measures and disease among racial or ethnic minority … Address correspondence to Elizabeth C. Matsui, MD, MHS, Departments of Population Health and Pediatrics, Dell Medical School, The University of Texas at Austin, 1701 Trinity St, Austin, TX 78712. E-mail: ematsui{at}utexas.edu

Traditional measures of socioeconomic status (SES) are associated with asthma morbidity, but their specific contributions are unclear. Increased exposure to indoor allergens among low SES children is an important consideration. Material hardship, a concept describing poor access to basic goods and services, may explain the relationship between low SES and indoor allergen exposure, and thereby, the increased risk of asthma morbidity. We sought to (i) describe the specific hardships experienced by low-Income, urban, minority children with asthma and indoor allergen sensitization and (ii) determine if material hardship is associated with indoor allergen exposure in this population. We conducted a cross-sectional analysis of children undergoing the baseline assessment for a clinical trial of home environmental modification. Participants were scored in five domains of material hardship. Domain scores were assigned based on caregiver responses to a questionnaire and were summed to generate a total material hardship score. Linear regression was used to examine the relationship between material hardship scores and bedroom floor concentrations of five common indoor allergens. Participants experienced high levels of material hardship in each of the five domains, with 33% not having access to a car, 35% not being able to pay utility bills, and 28% not being able to pay rent in the past year. Each one-point increase in material hardship was associated with an increase in cockroach allergen of 16.2% (95% CI: 9.4%, 24.6%) and an increase in mouse allergen of 9.4% (95% CI: 1.0%, 18.5%). After adjusting for traditional measures of SES, including household income, health insurance type, caregiver education, and caregiver employment status, the association between material hardship and cockroach allergen, but not mouse allergen, remained. These data suggest that a significant proportion of families of low-income, minority children with asthma may experience material hardship, and that they may be at greater risk of cockroach allergen exposure than their peers with similar income, but without material hardship.

Background The disrupted skin barrier in eczema has been associated with an increased risk of immunoglobulin E (IgE) sensitization in childhood. However, it is unclear whether eczema, independent of atopy, is a risk factor for the development of allergic sensitization in adulthood. Objective To determine if skin barrier dysfunction, independent of atopy, is a risk factor for incident sensitization in adult workers at a mouse production and research facility. Methods New employees at The Jackson Laboratory enrolled in a cohort study and underwent skin-prick testing (SPT) at baseline and every 6 months to mouse and to a panel of aeroallergens (net wheal ≥3 mm indicated a positive SPT result). Mouse allergen exposure was measured every 6 months by using personal air monitors. Physician-diagnosed eczema was defined as self-reported physician-diagnosed eczema. Cox proportional hazard modeling was used to examine the association between baseline physician-diagnosed eczema and incident mouse skin test sensitization and adjusted for potential confounders. Results The participants (N = 394) were followed up for a median of 24 months. Fifty-four percent were women, 89% were white, and 64% handled mice. At baseline, 7% of the participants reported physician-diagnosed eczema and 9% reported current asthma; 61% had at least one positive skin test result. At 30 months, 36% of those with eczema versus 14% of those without eczema had developed a positive mouse skin test result (p = 0.02, log-rank test). After adjusting for age, race, sex, smoking status (current, former, never), current asthma, hay fever, the number of positive SPT results at baseline, and mouse allergen exposure, physician-diagnosed eczema was an independent risk factor for incident mouse SPT sensitization (hazard ratio 5.6 [95% confidence interval, 2.1-15.2]; p = 0.001). Conclusion Among adult workers at a mouse production and research facility, physician-diagnosed eczema was a risk factor for incident mouse sensitization, independent of atopy, which indicated that a defect in skin barrier alone may increase the risk of skin sensitization, not just in childhood, but throughout life.

Background Whether concomitant home exposures modify the effectiveness of mouse allergen reduction among mouse-sensitized children with asthma is unknown. Objective To determine whether a lower baseline home mouse allergen level, lower particulate matter 10 μ or less (PM10), and the absence of sensitization and exposure to other indoor allergens are associated with greater improvements in asthma associated with mouse allergen reduction. Methods A secondary analysis of a randomized clinical trial of a home mouse allergen intervention was performed to examine the effect of 3 indoor factors on the relationship between mouse allergen reduction and a range of asthma outcomes. Results Participants (N = 297) were predominantly minority (78% African American, 22% Hispanic) and publicly insured (88%). Higher baseline mouse allergen levels were associated with a greater response to mouse allergen reduction for several symptom and exacerbation outcomes. Lower indoor PM10 levels were associated with a greater response to mouse allergen reduction for several symptom outcomes, but not exacerbation outcomes. Overall, sensitization and exposure to other indoor allergens did not appear to modify the effect of mouse allergen reduction. Conclusions In this population of predominantly low-income children with persistent asthma and mouse sensitization, mouse allergen reduction was associated with improvements in asthma, especially among those with high baseline mouse allergen exposure. Lower indoor PM10 was associated with greater improvements in asthma symptoms.

Background The extent to which asthma-related emergency department (ED) visit incidence rates vary from neighborhood to neighborhood and the predictors of neighorbood-level asthma ED visit burden are not well understood. Objective Our aim was to describe the census tract–level spatial distribution of asthma-related ED visits in Central Texas and identify neighborhood-level characteristics that explain variability in neighborhood-level asthma ED visit rates. Methods Conditional autoregressive models were used to examine the spatial distribution of asthma-related ED visit incidence rates across Travis County, Texas, census tracts and to assess the contribution of census tract characteristics to their distribution. Results There were distinct patterns in ED visit incidence rates at the census tract scale that were largely unexplained by socioeconomic or selected built environment neighborhood characteristics. Racial and ethnic composition explained 33% of the variability of ED visit incidence rates across census tracts. Spatial patterns and the census tract predictors of ED visit incidence rates differed by racial and ethnic groups. Conclusions Variability in asthma ED visit incidence rates are apparent at smaller spatial scales than previously examined. Most of the variability in census tract–level asthma ED visit rates in Central Texas is not explained by racial and ethnic composition or other neighborhood features. Race/ethnicity-specific estimates of neighborhood ED visit rates may be useful for identifying high-burden neighborhoods for specific ethnic and racial groups that otherwise would go unrecognized.

Despite the recommendation in national asthma guidelines to target indoor environmental exposures, most insurers generally have not covered the outreach, education, environmental assessments, or durable goods integral to home environmental interventions. However, emerging payment approaches offer new potential for coverage of home-based environmental intervention costs. These opportunities are becoming available as public and private insurers shift reimbursement to reward better health outcomes, and their key characteristic is a focus on the value rather than the volume of services. These new payment models for environmental interventions can be divided into 2 categories: enhanced fee-for-service reimbursement and set payments per patient that cover asthma-related costs. Several pilot programs across the United States are underway, and as they prove their value and as payment increasingly becomes aligned with better outcomes at lower cost, these efforts should have a bright future. Physicians should be aware that these new possibilities are emerging for payment of the goods and services needed for indoor environmental interventions for their patients with asthma.

F Rusconi, L Gagliardi, E Gori. Pediatr Allergy Immunol. 2019;30(7):732–738 To examine associations between maternal mental health and early childhood wheezing and infections. 2314 mother-child pairs from an Italian birth cohort. Maternal mental health was measured using the General Health Questionnaire-12 (GHQ-12), a validated screening instrument for non-psychotic psychiatric morbidity, at the end of pregnancy and one year after delivery. Child outcomes were assessed at 24 months. Wheezing between 12 and 24 months of age was assessed using validated ISAAC questions. Upper respiratory infections (URIs), lower respiratory tract infections (LRTIs), …

Background Although poor-urban (inner-city) areas are thought to have high asthma prevalence and morbidity, we recently found that inner cities do not have higher prevalent pediatric asthma. Whether asthma morbidity is higher in inner-city areas across the United States is not known. Objective This study sought to examine relationships between residence in poor and urban areas, race/ethnicity, and asthma morbidity among children with asthma who are enrolled in Medicaid. Methods Children aged 5 to 19 enrolled in Medicaid in 2009 to 2010 were included. Asthma was defined by at least 1 outpatient or emergency department (ED) visit with a primary diagnosis code of asthma over the 2-year period. Urbanization status was defined at the county level and neighborhood poverty at the zip-code level. Among children with asthma, logistic models were created to examine the effects of urbanization, neighborhood poverty, and race/ethnicity on rates of asthma outpatient visits, ED visits, and hospitalizations. Results This study included 16,860,716 children (1,534,820 with asthma). Among children enrolled in Medicaid, residence in inner-city areas did not confer increased risk of prevalent asthma in either crude or adjusted analyses, but it was associated with significantly more asthma-related ED visits and hospitalizations among those with asthma in crude analyses (risk ratio, 1.48; 95% CI, 1.24-1.36; and 1.97; 95% CI, 1.50-1.72, respectively) and when adjusted for race/ethnicity, age, and sex (adjusted risk ratio, 1.23; 95% CI, 1.08-1.15; and 1.62; 95% CI, 1.26-1.43). Residence in urban or poor areas and non-Hispanic black race/ethnicity were all independently associated with increased risk of asthma-related ED visits and hospitalizations. Conclusions Residence in poor and urban areas is an important risk factor for asthma morbidity, but not for prevalence, among low-income US children.

The bacterium Staphylococcus aureus (SA) is known to induce allergic inflammatory responses, including through secreted staphylococcal enterotoxin (SE) superantigens. To quantify indoor environmental exposures to these potential allergens, which may be associated with worse asthma, we developed a method for the assessment of S. aureus and SE in home dust and applied it to a study of homes of inner-city adults with asthma.We conducted laboratory experiments to optimize sample processing and real-time PCR methods for detection and quantification of SA (femB) and SEA-D, based on published primers. We applied this method to dust and dust extract from 24 homes. We compared results from real-time PCR to culture-based results from the same homes.The bacteremia DNA isolation method provided higher DNA yield than alternative kits. Culture-based results from homes demonstrated 12 of 24 (50%) bedrooms were contaminated with S. aureus, only one of which carried a SE gene (SEC). In contrast, femB was detected in 23 of 24 (96%) bedrooms with a median of 1.1×10Our culture-independent method to detect S. aureus and SE in home dust was more sensitive than our culture-based method. Prevalence of household exposure to S. aureus and SE allergens may be high among adults with asthma.

Bulk sampling of aerosols is often needed for the determination of physical properties, chemical composition and toxicity assessments of airborne particulate matter. Conventional aerosol samplers have several limitations for use as bulk aerosol collectors including cost, noise levels, power requirements associated with the use of a pump, limited flow rate, and a relatively long sampling time needed to collect sufficient mass to achieve gravimetric or other method limits of detection. In this study, a low-cost ionic charging device (ICD) was evaluated that addresses many of the drawbacks of conventional aerosol samplers. Different types of particles including incense fume, Arizona Road Dust (ARD) powders and Polystyrene Latex (PSL) spheres of different sizes were aerosolized then sampled using three ICDs and compared to conventional inhalable and PM2.5 (particulate matter with aerodynamic diameter less than 100 µm and 2.5 µm, respectively) aerosol samplers in a controlled laboratory chamber at varying concentrations. The device was also evaluated in indoor environments. ICDs operate at almost 18.5 times higher flow rate than conventional personal samplers and provided up to 9 times greater total collected mass compared to the conventional samplers over the same time frame. Using a regression analysis, aerosol-specific linear equations with slopes (CPM2.5/CICD) from 1.21 to 7.10 and R2 from 0.74 to 0.99 for estimating the inhalable and PM2.5 mass concentrations using the ICD were derived. This study suggests that the ICD provides a less accurate estimate of size-selective PM mass concentrations than conventional personal aerosol samplers; however, it collects coarse particles efficiently and increases total sampled mass per time at a lower cost and without noise associated with traditional sampling methods. Therefore, the ICD can be used as a bulk aerosol collector for composition analyses and in-vitro toxicology tests of coarse PM.